Remote RN Reviewer: Prior Auth & Care Quality

Cohere Health, Inc.; United States; On-site; USD 68,640 - 72,800; Full time

Benefits offered by this job

Fully remote opportunity

Company 401(k) with match

PTO and parental leave

Job summary

Cohere Health, Inc. seeks an RN Reviewer for a 100% remote role in the United States. You will assess medical necessity across inpatient, outpatient, and post-acute requests, supporting cost-effective care and compliance with NCQA/CMS guidelines.

You’ll collaborate with Medical Directors and providers, document reviews, and contribute to quality initiatives. Requires an active RN license, 3+ years of clinical experience, and comfort with Mac and Google Workspace.

Qualifications

• Active, unencumbered RN license (state of residence).
• 3+ years of clinical experience in acute or post-acute settings.
• Experience with utilization review and prior authorization. (MAC/Google Workspace familiarity helpful).
• Knowledge of NCQA/CMS standards; familiarity with MCG (CareWebQI).

Responsibilities

• Review medical necessity for inpatient, concurrent, prior auth, and retrospective cases.
• Collaborate with Medical Directors and providers to align on clinical decisions.
• Document reviews accurately and meet production/quality goals.
• Apply MCG, Cohere, and coverage guidelines for compliance and consistency.
• Partner across teams to improve processes and outcomes.
• Identify opportunities for care management or quality improvement programs.
• Support accreditation, regulatory, and quality initiatives.

Skills

RN License

3+ years clinical

Utilization Review

HEDIS abstraction

MCG CareWebQI

Communication

Remote collaboration

Education

BSN

Bachelor's degree in Nursing or related field

Tools

Mac

Google Workspace

Job description

Cohere Health, Inc. seeks an RN Reviewer for a 100% remote role in the United States. You will assess medical necessity across inpatient, outpatient, and post-acute requests, supporting cost-effective care and compliance with NCQA/CMS guidelines.

You’ll collaborate with Medical Directors and providers, document reviews, and contribute to quality initiatives. Requires an active RN license, 3+ years of clinical experience, and comfort with Mac and Google Workspace.